Evaluating Modern Spacer Options and Outcomes in Revision Hip Arthroplasty.

BACKGROUND: A 2-stage revision continues to be the standard treatment for periprosthetic joint infection (PJI) in hip arthroplasty. The use of "functional" spacers may allow patients to return to daily living while optimizing their health for revision surgery. We aimed to evaluate the clinical outcomes of different spacer types regarding infection eradication, mechanical complications, and functional outcomes. METHODS: Patients who have complete Musculoskeletal Infection Society criteria for diagnosis of PJI that underwent one-stage or 2-stage revision were queried in an institutional surgical database between 2002 and 2022. Out of 286 patients, 210 met our inclusion criteria and were retrospectively reviewed for demographics, laboratory values, functional and patient-reported outcomes, and subsequent revisions. The study population had 54.3% women, a mean age of 61 years old, and a mean follow-up of 3.7 ± 3.2 years. There was no difference between age, body mass index, or Charlson Comorbidity Index scores between each cohort. Spacers were categorized as nonfunctional static, nonfunctional articulating, or functional articulating. Functional spacers were defined as those that allowed full weight bearing with no restrictions. Delphi criteria were used to define revision success, and failure was defined as a recurrent or persistent infection following definitive surgery. RESULTS: There was a significantly lower reoperation rate after a definitive implant in the functional articulating cohort (P = .003), with a trending higher infection eradication rate and a lower rate of spacer failure compared to the nonfunctional spacer cohort. At 5 years, functional articulating spacers had a 94.1% survivorship rate, nonfunctional articulating spacers had an 81.2% survival rate, and nonfunctional static spacers had a 71.4% survival rate. In the functional articulating spacer cohort, 14.6% had yet to get reimplanted, with an average follow-up time of 1.4 years. CONCLUSIONS: Within this large cohort of similar demographics, functional articulating spacers may result in better clinical outcomes and infection eradication during 2-stage revision arthroplasty for PJI.

Lactic acid levels are associated with morbidity, length of stay, and total treatment costs in urban trauma patients with lower extremity long bone fractures.

INTRODUCTION: Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. METHODS: Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. RESULTS: A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). CONCLUSION: High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. LEVEL OF EVIDENCE: III.

Validation of a Classification System for Optimal Application of Debridement, Antibiotics, and Implant Retention in Prosthetic Joint Infections following Total Knee Arthroplasty: A Retrospective Review.

INTRODUCTION: Periprosthetic joint infection (PJI) remains a serious complication after total knee arthroplasty (TKA). While debridement, antibiotics, and implant retention (DAIR) are considered for acute PJI, success rates vary. This study aims to assess a new scoring system's accuracy in predicting DAIR success. METHODS: 119 TKA patients (2008-2019) diagnosed with PJI who underwent DAIR were included for analysis. Data were collected on demographics, laboratory values, and clinical outcomes. This was used for validation of the novel classification system consisting of PJI acuteness, microorganism classification, and host health for DAIR indication. Statistical analysis was carried out using SPSS programming. RESULTS: Mean follow-up was 2.5 years with an average age of 65.5 ± 9.1 years, BMI of 31.9 ± 6.2 kg/m2, and CCI of 3.04 ± 1.8. Successful infection eradication occurred in 75.6% of patients. The classification system demonstrated 61.1% sensitivity, 72.4% specificity, and 87.3% positive predictive value (PPV) when the DAIR cutoff was a score less than 6. For a cutoff of less than 8, sensitivity was 100%, specificity was 37.9%, and PPV was 83.3%. CONCLUSIONS: To date, no consensus exists on a classification system predicting DAIR success. This novel scoring system, with high PPV, shows promise. Further refinement is essential for enhanced predictive accuracy.

Preoperative Corticosteroid Injections Are Not Associated with Deep Infection after Unicompartmental Knee Arthroplasty.

Prior to unicompartmental knee arthroplasty (UKA), corticosteroid injections (CSI) are a common nonoperative treatment for arthritis. It is unclear whether CSI prior to UKA impacts the likelihood of postoperative infection. This study sought to determine if there is a time- and/or dose-dependent relationship between preoperative CSI and postoperative infection. An administrative claims database was queried for patients undergoing UKA with more than 1 year of pre-enrollment and follow-up. Of 31,676 patients with a UKA who met enrollment criteria, 8,628 patients had a CSI 0 to 3 months prior to surgery, 111 had a CSI 3 to 12 months prior to surgery, and 22,937 never received an injection. Overall, 246 postoperative deep infections were reported (0.8%). Time-dependent and dose-dependent relationships were modeled using multivariable logistic regressions. Postoperative deep infections occurred in 64 patients with CSI 0 to 3 months prior to surgery (0.7%), compared with 0 patients with CSI 3 to 12 months before surgery (0.0%) and 182 controls (0.8%, p = 0.58). CSI within 1 month prior to UKA was not statistically associated with postoperative infection (p = 0.66). Two or more CSI within 3 months prior to UKA were associated with a twofold elevated odds of infection, compared with receiving a single injection (odds ratio [OR]: 2.08, p = 0.03). Univariable predictors of infection included younger age, increasing Charlson Comorbidity Index, smoking, asthma, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, liver disease, and obesity. Multivariable analysis controlling for these characteristics elicited no relationship between recent CSI administration and postoperative infection. CSI within 3 months of surgery (1.5%) or 3 to 12 months (1.8%) were associated with increased conversion to total knee arthroplasty (TKA) compared with those who did not receive an injection (1.1%, p = 0.01), although TKA for indication of periprosthetic joint infection was not statistically different (p = 0.72). Preoperative CSI within 3 months of UKA is not associated with postoperative infection, although significant medical comorbidity does show an association. Preoperative CSI is associated with increased conversion from UKA to TKA for noninfectious indications.

Modern Description of Antibiotic Spacer Options for PJI in Revision Total Knee Arthroplasty: Clinical Outcomes and Infection Eradication Rates.

BACKGROUND: As the burden of periprosthetic joint infections (PJIs) increases, there is growing interest in understanding the efficacy and morbidity reduction of 2-stage revision and various antibiotic spacer options. This study aimed to expand the description and evaluation of spacers from solely their articulation status to include their ability to support full (functional) or partial weight-bearing (nonfunctional). METHODS: Between 2002 and 2021, 391 patients who had Musculoskeletal Infection Society criteria for PJI with 1-stage or 2-stage revision were included. Demographics, functional outcomes, and subsequent revision data were collected. The study population had a mean follow-up of 2.9 years (range, 0.05-13.0) with an average age of 67 years (range, 34.7-93.4). Spacer failure was defined by surgical intervention following definitive surgery, and infection eradication was defined by the Delphi criteria. Spacers were classified as nonfunctional static, nonfunctional dynamic, functional static, or functional dynamic. Two tailed t-tests were performed. RESULTS: There were no significant differences in infection eradication or mechanical outcomes across spacer types; notably, 97.3% of functional dynamic spacers achieved infection eradication. Functional spacers had a longer time to the second stage procedure and a greater number of patients who had not been reimplanted. There was no difference in reoperation rates in nonfunctional versus functional spacers. CONCLUSION: Within this cohort, infection eradication and spacer exchange rates were noninferior among spacers. Functional spacers may allow for earlier return to daily living given the weight-bearing capability when compared to nonfunctional, without sacrificing clinical outcome.

Racial Differences in Readmissions in Hypertensive Disorders of Pregnancy.

Hypertensive disorders of pregnancy (HDP) are associated with maternal and neonatal morbidity as well as postpartum hospital readmission. This study seeks to characterize differences among patients with postpartum readmissions related to HDP. This is a retrospective study of patients with HDP admitted at an urban tertiary care center from January 2019 to November 2019 following the implementation of a standardized readmission workflow for patients with HDP at a single institution. Medical information up to 6 weeks postpartum was collected by chart review. The primary outcome was readmission. Secondary outcomes included reason for readmission, location of initial evaluation, and blood pressure values at time of readmission. A total of 729 patients with HDP delivered over the study period, 79.7% (N = 581) of whom were Black and 11.0% (N = 80) of all patients were readmitted within 6 weeks of delivery. Patients who were older, privately insured, and with chronic hypertension/cardiac disease were more likely to be readmitted. There was no difference in readmission rate by race. However, Black patients were more likely to be readmitted for preeclampsia with severe features (43.3% vs 10.0% non-Black, p = 0.01). Black patients who were readmitted were more likely to be initially evaluated in the emergency room compared to non-Black patients (43.3% vs 15.0%, p = 0.03). Our results suggest although readmission rates did not differ by race, there are significant differences at the patient and system level between Black and non-Black patients readmitted to the hospital after a pregnancy affected by HDP.

A Retrospective Review of Relative Value Units in Revision Total Knee Arthroplasty: A Dichotomy Between Surgical Complexity and Reimbursement.

BACKGROUND: Revision total knee arthroplasties (TKA) are costly, time-intensive, and technically demanding procedures. There are concerns regarding the valuation of Current Procedural Terminology (CPT) codes and the assigned relative value units (RVU) as a potential disincentive to perform revision TKAs. This study evaluated the labor and time investment for each component-specific revision and assessed the disparities between procedural value billed and reimbursement. METHODS: A retrospective review of 154 primary and revision TKA cases were thoroughly vetted using operative notes and internal billing data. Revision TKAs were stratified by single femoral component, single tibial component, polyethylene liner only, all-component, and spacer placement for prosthetic infection. Operative time, RVUs billed, total charges, deductions, and reimbursements were recorded. Mann-Whitney U tests compared final reimbursement per minute and per RVU between revision and primary TKAs. RESULTS: There were 28 primary TKAs, 11 femoral component revisions, 25 tibial component revisions, 25 liner exchanges, 37 all-component revisions, and 28 spacer placements. Revisions involving the tibial component, all-components, and placement of spacers were reimbursed less dollars per minute than primary TKAs (P < .05). Controlling for RVUs, liner exchanges and all-component revisions had fewer dollars per RVU than primary TKAs (P < .05). CONCLUSION: As revision complexity increases, physicians face less reimbursement per minute and per RVU. With reductions set by CMS and private insurers, revisions may be financially unfavorable and lead to restrictions and access to care problems. Our data supports the need for reevaluating RVU allocation amongst revision procedures with potential updates to the CPT coding system.

A Retrospective Review of Reimbursement in Revision Total Hip Arthroplasty: A Disparity Between Case Complexity and RVU Compensation.

BACKGROUND: Revision total hip arthroplasties (THA) are time-consuming, expensive, and technically challenging. Today's Current Procedural Terminology (CPT) codes and relative value units (RVU) may in fact disincentivize surgeons to perform revision THAs. Our study reviewed labor and time investments for each component-specific revision THA and analyzed the gap between procedural value billed and final reimbursement. METHODS: A retrospective review of 165 primary and revision THAs were validated using operative notes and billing records. We stratified revision THAs by standard CPT coding (with modifiers) as single acetabular component, single femoral component, femoral head plus polyethylene liner (head/liner) exchange, all-components, and spacer placement for infection. Operative time, RVUs, total charges, deductions, and final reimbursement data was collected. Mann-Whitney U tests studied final reimbursement per minute vs per RVU in revision and primary THAs. RESULTS: Our cohort consisted of 27 primary THAs, 26 acetabular component revisions, 32 head/liner exchanges, 26 femoral component revisions, 27 all-component revisions, and 27 spacer placements. Compared to primary THAs, every revision subgroup except for head/liner exchanges were found to reimburse less per minute and all revision subgroups reimbursed less per RVU (P < .05). CONCLUSION: Physicians face less reimbursement per minute and per RVU for revision THAs. With cuts in reimbursement set forth by Centers for Medicare and Medicaid Services (CMS) and insurers, revisions may be financially unfavorable. This ultimately will lead to an impending access to care problem in the future. Our study supports the need to re-examine the RVU allocation amongst revision THAs and evaluate changes to the Current Procedural Terminology (CPT) coding system.

Elimination of racial disparities in postpartum hypertension follow-up after incorporation of telehealth into a quality bundle.

BACKGROUND: Black people have a disproportionately higher risk of hypertensive disorders of pregnancy and postpartum complications than White people but historically lower rates of postpartum follow-up. Few studies have investigated telehealth in the postpartum population. OBJECTIVE: This study aimed to investigate whether rapid switch to telehealth with audio-based visits during the COVID-19 pandemic decreased racial disparities in postpartum hypertension follow-up adherence. STUDY DESIGN: This retrospective cohort study included all the patients with hypertensive disorders of pregnancy who delivered between December 2019 and June 2020 at an urban tertiary care center. A preexisting postpartum hypertension quality improvement initiative was in place at this institution. Follow-up adherence within 6 weeks postpartum and at the 6-week visit were compared before February 15, 2020 (pretelehealth period) and following March 14, 2020 (post-telehealth period), with a 1-month implementation or washout period. The blood pressures at these visits were compared between time periods as a secondary outcome. RESULTS: A total of 473 patients were included in this analysis, of whom 76.3% were non-Hispanic Black. There were 215 and 258 patients in the pre- and post-telehealth cohorts, respectively. Among those who attended follow-up, the proportion of visits done over telehealth went from 0% pretelehealth to 98.0% post-telehealth. The proportion of postpartum hypertension follow-up attendance changed from 48.5% to 76.3% among non-Hispanic Black people (P<.0001) and from 73.1% to 76.7% among non-Hispanic White people (P=.76), leaving only a 0.4% racial gap (P=.97). This resulted in an elimination of the racial disparities in the post-telehealth period. CONCLUSION: Transition to telehealth with audio-based visits at the onset of the COVID-19 pandemic improved attendance at postpartum hypertension visits among non-Hispanic Black people. This, therefore, led to significant decreases in the racial disparities in follow-up rates at our institution in the setting of an existing quality improvement initiative. Further research should focus on the intentional use of telehealth in improving maternal outcomes, especially among the non-Hispanic Black people.